Inaccurate MDS Coding for Admission and PASRR Status
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for two residents. One resident with non-Alzheimer's dementia and Parkinson's disease was re-admitted to the facility following a hospital stay for surgical repair of a right hip fracture. The significant change MDS assessment completed after re-admission was incorrectly coded, as it should have been marked as the first assessment following re-entry. This error was acknowledged by the MDS nurse, who stated the assessment was not coded accurately. Another resident with diagnoses including paranoid schizophrenia and anxiety disorder had a Level 2 Pre-admission Screening and Resident Review (PASRR) determination indicating the need for specialized services due to serious mental illness. However, the significant change MDS assessment did not reflect the updated PASRR status, as the resident profile had not been updated from Level 1 to Level 2. The MDS Coordinator and Social Services staff confirmed that the PASRR information was not current in the electronic medical record at the time of the assessment, resulting in inaccurate MDS coding.